Determinants of Neonatal Jaundice among Neonates Admitted to Neonatal Intensive Care Unit at Dr. Jamal Ahmed Rashid Pediatric Teaching Hospital in Sulaymaniyah City/Iraq

INTRODUCTION

Neonatal jaundice (NJ) is an excessive buildup of bilirubin in the neonatal body, which causes a yellow coloring of the skin, sclera, and mucosa (Lake et al., 2019). It is one of the most prevalent illnesses, affecting up to 60% of full-term and 80% of preterm neonates (Slusher et al., 2004). Neonatal have a significantly greater bilirubin level than adults due to the erythrocytes' shorter lifespan and less ability to eliminate bilirubin; however, Hyperbilirubinemia, often known as jaundice, is a potentially fatal condition in newborns (Ullah et al., 2016). Although NJ is a clinical issue that may be avoided and managed, it can cause infant death if treatment is not received (Sharrow et al., 2022). 

Globally, NJ impacts 1.1 million neonates annually (Adugna & Ado, 2023). The burden was most significant in low- and middle-income countries in Sub-Saharan Africa and South Asia (Olusanya & Slusher, 2015). A study conducted in Nigeria revealed that NJ constituted 35.0% of total NICU admissions. Ethiopia ranks among the top ten countries for neonatal mortality associated with jaundice.(Greco et al., 2016). Research from Addis Ababa, Ethiopia, and the University of Gonder revealed that the prevalence of NJ was 13.3% and 24.6%, respectively (Adugna & Ado, 2023).

The primary risk factors for NJ include Rh incompatibility, ABO, and diabetes mellitus, which are maternal risk factors. NJ is known to be caused independently by low birth weight, sepsis, birth injury, prematurity, glucose-6-phosphate dehydrogenase deficiency (G6PD), polycythemia, male sex, breastfeeding, and a family history of jaundice (Zauk, 2015). According to a study done in developed countries, the primary cause of neonatal jaundice is blood incompatibilities; however, in developing countries, the primary causes of neonatal jaundice were low birth weight, infection, prematurity, and glucose 6-phosphate deficiency (Ip et al., 2004).

Numerous measures have been taken to lower the morbidity and fatality rates related to newborn jaundice. These interventions include blood group screening during antenatal care (ANC) with the provision of Anti-D for mothers who have Rh negative status during pregnancy and postpartum, genetic screening to identify enzymatic deficiencies, and teaching mothers to recognize the early signs of jaundice and seek timely healthcare services (Birhanu et al., 2022).

MATERIAL AND METHOD

A quantitative design (descriptive) study case-control method was used to achieve the study's objectives.

A non-probability purposive sampling technique was used to select (50) cases diagnosed with jaundice in the NICU at Dr. Jamal Ahmed Rashid Pediatric Teaching Hospital as the case group, and (50) neonates in the same unit who were not suffering from jaundice were selected as the control group. The samples were chosen according to the following: neonates diagnosed with jaundice and mothers willing to participate in the study.

Methods of data collection: -

Before interviewing the mothers, an introduction was given, and the researcher personally explained the purpose of the study to the subjects to achieve verbal informed consent. The researcher then held a face-to-face interview, and data was collected using the constructed questionnaire from January 5th to April 5th, 2023.

Tools and Measurement: -

To collect the proper data, the researcher developed a questionnaire form based on a review of literature and previous studies to measure the variables underlying the present study. The study questionnaire consists of three parts, which are distributed as follows:

Part one: Socio-demographic characteristics of mothers consist of five items: age, marital status, level of education, occupation, and residency.

Part two: Obstetrics and social-related characteristics of mothers consists of nine items, which include a previous child history of neonatal jaundice, antenatal care follow-up, complications during pregnancy, blood group, Rh incompatibility, gestational age, prolonged labor, mode of delivery, and gravidity.

Part three: Socio-demographic characteristics of neonates consist of four items: age, gender, birth weight, and feeding options.

Administrative arrangement: -

An official letter has been submitted from the College of Nursing to Sulaymaniyah, General Directorate of Health (DOH), to obtain facilitation and cooperation during the study's data collection. Consequently, an agreement letter has been submitted from DOH to Dr. Jamal Ahmed Rashid, Pediatric Teaching Hospital. This research study has received ethical approval from the ethics committee of the College of Medicine and the University of Sulaymaniyah, Iraq.

Statistical Analysis: -

The study data were analyzed using a statistical package for social sciences through descriptive analysis (frequency, percentages) for all variables to achieve the stated objectives. The inferential statistical method, chi-square, was used to determine the association between socio-demographic characteristics and neonatal jaundice. (P value ≤ 0.05) was considered the level of significance.

RESULTS

Socio-demographic characteristics

The study included 100 mothers and their neonates, comprising 50 cases and 50 controls. Mothers aged 20 to 35 had the highest proportion of cases, 78%, compared with controls, 60%, and the mean ages of cases and controls were 29.44 ± 6.04 and 31.06 ± 6.98, respectively. The vast majority of mothers in both the case and control groups were married, which accounts for 96% and 94%, respectively. In both cases and controls, the highest percentages of mothers graduated from an institute or university, which accounts for 54% and 50%, respectively. Regarding mothers’ occupations, the proportion of unemployed mothers in both case and control groups records the highest percentage, 72% and 60%, respectively. Regarding residency, in both case and control groups, the highest percentage of families were living in urban areas, which accounts for 76% and 62%, respectively, and very few percentages in both groups were living in rural areas (Table 1).

Obstetrics characteristics

Approximately three-quarters of 74% of cases and 92% of controls have no previous child history of neonatal jaundice. Regarding follow-up of antenatal care, the majority, 82% of cases, and 86% of controls had ANC follow-up. Less than two-thirds

72% of cases and 82% of controls have no complications during pregnancy. The blood group of mothers was assessed and recorded as A, B, AB, and O; the highest proportion, 36% of cases, were in the O group, and the highest proportion, 54%, of controls did not know their blood groups. The proportion of mothers with no Rh incompatibility with their neonates was 82% for cases and 92% for controls. According to gestational ages, the proportion of term neonates was lower among cases, 58%, compared to controls, 74%. Concerning prolonged labor, 70% of cases and 80% of the controls had normal labor during delivery. Concerning the mode of delivery, 70% of cases and 82% of controls were delivered through C/S. Regarding gravidity, 54% of cases and 70% of controls were multigravida.

Neonatal characteristics

Table (3) represents some of the demographic characteristics of neonates in both the case and control groups. About the neonate age, 58% of cases and 66% of controls were between 2-7 days, and the mean ages of cases and controls were 3.06 ± 2.24 and 6.74 ± 4.840, respectively. In the case group, the highest % of samples, 70%, were male, and the rest of the neonates were female, but in the control group, the proportion of males was 52%. The proportion of low birth weight was higher among cases, 62%, compared with controls at 18%. The proportion of neonates with formula feed was higher among cases at 50%, compared with controls at 32%. Risk factors associated with neonatal jaundice Tables (4, 5, and 6) display the association between maternal, obstetrics, and neonatal risk factors with neonatal jaundice. Regarding maternal demographic factors, there was no significant association between maternal demographic factors and neonatal jaundice. Regarding obstructive factors, there was a significant association between a previous child's history of NJ (p = 0.017) and neonatal jaundice. There was a significant association between blood group (p = 0.037) and neonatal jaundice. For neonatal risk factors, there was a significant association between sex (p=0.05), birth weight (p=0.000), and feeding option (p=0.049) with neonatal jaundice.

RESULT

Table (1) Distribution of sample according to maternal sociodemographic characteristics in cases and controls

Table (2) sample distribution according to obstetrics-related characteristics in both cases and control groups.

Table (3) Distribution of sample according to neonatal characteristics in both cases and control groups.

Table (4) association between cases & and control groups in relation to maternal sociodemographic characteristics

Table (5) association between cases & controls group about obstetrics characteristics

Table (6) association between case-control groups about neonatal characteristics

DISCUSSION

This study found that mothers between 20 and 35 comprised 78% of cases compared to 60% of controls. This is similar to the results of a study by Sisay et

83. (2023), which also found that 83.33% of mothers were between the ages of 20 and
84. Most mothers in both case and control groups were married. This finding agrees with the results of a study by (Adugna and Ado, 2021), who found that most parents in their study were living together. In both cases and controls, most mothers graduated from an institute or university, which accounts for 54% and 50%, respectively. The findings in the present study disagree with the findings of Hamad& Khalil (2019) in Soran City reported that the highest percentage, 31% of mothers, were illiterate, followed by 23%, and 23% were university/institute and secondary, respectively.

Concerning mothers' occupations, the highest proportions of mothers were unemployed. This result is consistent with a previous study conducted by Belay et al.

(2023) showed that 76.1% of mothers were unemployed. Regarding residency in both case and control groups, the highest percentage of families lived in urban areas. This finding is consistent with a previous study conducted by Asefa et al. (2020), which reported that 65.7% of samples lived in urban areas and 34.3% in rural areas. 

Most controls and approximately three-quarters of cases have no previous history of newborn jaundice. This finding aligns with another study that found 93.6% of controls and 85.9% of cases had no previous history of neonatal jaundice (Bizuneh et al., 2020). In terms of prenatal care follow-up, the majority of

cases and controls had prenatal care follow-up during pregnancy. This finding is consistent with the study by Adugna & Ado (2021), which revealed that 77.2% of cases and 93% of controls had prenatal care follow-ups. Less than three quarters, 72% of cases and 82% of controls do not have any obstetric complication; this is in line with Asefa et al. (2020) findings, which show that the highest percentage, 78% of cases and 82% of controls do not have complications during pregnancy.  Over one-third of cases were in the O blood group, and over half of the controls did not know their blood groups. According to prolonged labor, 70% of cases and 80% of controls have normal labor, and the majority of cases and controls had no Rh incompatibility; these results are confirmed by Kiros et al. (2023), who found that 26.7% of cases were O blood group, 83.3% of cases and 76.7% of controls were normal labor, and 91.7% of cases and 99.2% of controls do not have Rh incompatibility. Regarding gestational ages, the proportion of term neonates was lower among cases, 58%, compared to controls, 74%.  A cross-sectional study conducted in Bahrain by Isa et al. (2022) found that 21.8% of jaundiced neonates were preterm and 78.2 % were term. Concerning the mode of delivery, 70% of cases and 82% of controls were delivered through C/S. This aligns with Abd Elmoktader et al. (2019), who found in their study that neonates delivered by NVD were 28.1 % of neonates and 71.9 % of neonates delivered by CS. More than two-thirds of the controls and more than half of the cases were multigravida; this finding agrees with the study done by Tessema et al. (2024), who found that 67% of the respondents were multigravida.

Regarding neonatal socio-demographic characteristics, 58% of cases and 66% of controls were between 2 and 7 days. This result is consistent with a study conducted by Bizuneh et al. (2020), which revealed that 67.1% of cases and 66.8% of controls were between 2 and 7 days. Regarding neonatal gender, over two-thirds of the samples in the case group and over half of the samples in the control group were male. This result aligns with a study by Bante et al. (2024) that showed that 70% of the study samples were male. The proportion of low birth weight was higher among cases, 62%, compared to controls, 18%. Regarding feeding practices, the case group had the highest percentage of formula-fed neonates, 50%, compared to the control group, 32%. This finding agrees with a study by Adugna & Ado (2021), which found that 67.1% of neonates had low birth weights and 49.4% were formula-fed. Neonatal gender, birth weight, feeding options, previous child history of NJ, and blood group were associated risk factors with neonatal jaundice. In this study, there was a positive relationship between jaundice and gender. This finding is in line with a previous study in Zakho City conducted by Mohammad et al. (2024), which found that male neonates presented with jaundice at higher rates. Male newborns are always more susceptible to neonatal jaundice, although the cause remains unknown (Garosi et al., 2016). According to this study, one of the determinants of NJ was the neonates' birth weight. This finding was in line with a study conducted by Murekatete et al. (2020), who found a significant association between newborn sex and jaundice and confirmed it as a risk factor associated with neonatal jaundice; this might be because most of the time, low birth weight is typical in newborns with prematurity who present with immature organs, particularly immature livers, which fail to conjugate normally and produce bilirubin from red blood cells, which results in jaundice (Bizuneh et al., 2020). This study revealed that neonatal jaundice was positively associated with mixed feeding. The study found that the ratio of breastfed to artificially fed newborns in both groups is nearly equal; hence, this non-significant difference might be referred to as a fact (Abdelgader et al., 2022). In this study, the history of jaundice in previous children was a factor related to jaundice. 

Saber et al. (2013) conducted studies to determine the risk factors for jaundice. The findings of their study revealed a significant association between neonatal jaundice and

a history of jaundice in previous infants. This study had a positive relationship between jaundice and the AB blood group. In contrast, the previous study in Ethiopia conducted by Asefa et al. (2020) found that the maternal O blood group was the determinant of neonatal jaundice among neonates admitted to the NICU.

CONCLUSION

Neonatal gender, birth weight, feeding options, previous child history of NJ, and blood group were crucial risk factors for neonatal jaundice. Further investigation into the prevalence and risk factors of newborn jaundice in other Kurdistan areas is necessary because it remains a common health problem. Therefore, early prevention and rapid treatment of neonatal jaundice are essential to prevent long-term effects and infant mortality.

 FUNDING:

The authors received no special funding to perform this study.

CONFLICT OF INTEREST

The writers announce that there is no conflict of interest between them.

The methodological quality of the included studies was assessed using the Cochrane Collaboration's Risk of Bias tool for RCTs, the Newcastle-Ottawa Scale for cohort studies, and other relevant quality assessment tools. The risk of bias varied across studies, with common issues including lack of blinding, incomplete outcome data, and selective reporting.